A Colles fracture is a transverse fracture through the distal 2 to 3 cm of the radial metaphysis where the distal fragment is dorsally displaced and angulated. The most common mechanism is a fall on an outstretched hand.

 Closed reduction is indicated if distal fragment has a dorsal tilt >10 degrees, an intra-articular fracture is present and has a >1 mm step-off, or there is >2 mm radial shortening

 General goals are to reduce displaced fragments and maintain reduction during healing

CONTRAINDICATIONS

 Hematoma block contraindicated if:

    History of allergy to local anesthetics

    Overlying skin infection or dirty skin

 Reduction contraindicated if open fracture exists

PROCEDURAL RISKS/CONSENT ISSUES

 Pain (site of needle insertion)

 Bleeding (local at needle puncture site)

 Infection (theoretical risk of iatrogenic infection)

LANDMARKS: RADIOGRAPHIC

 Standard radiographs should include a posteroanterior (PA) and a lateral projection

 Clearly describe fractures as pediatric or adult, extra-articular or intra-articular, comminuted or noncomminuted, angulated or not angulated

 In adults, several measurements are used to determine the extent of deformity

    Radial height (PA view): Two parallel lines drawn perpendicularly to the long axis of the radius, one through the tip of the radial styloid and the other at the articular surface of the radius

       Normal radial height is 9.9 to 17.3 mm

    Radial inclination (PA view): A line drawn through the articular surface of the radius, perpendicular to its long axis. A line is then drawn tangent from the tip of the radial styloid.

       Normal radial inclination is 15 to 25 degrees

    Volar tilt (lateral view): A line drawn perpendicularly to the long axis of the radius. A line is then drawn tangent to it along the articular surface from the dorsal to palmar surface of the radius.

       Normal volar tilt is 10 to 25 degrees

SUPPLIES

 Povidone–iodine or chlorhexidine solution

 25-gauge needle and 10- to 20-mL syringe for hematoma block

 Local anesthesia: 1% lidocaine without epinephrine or bupivacaine 0.5%

 Reduction materials: Gauze bandage roll for finger trap, traction weights (8–10 lb)

 Splinting materials: Web roll, plaster, elastic compression bandage

TECHNIQUE

 Clinical Assessment

    Inspection: Identify the skeletal deformity. Classic finding is the so-called dinner-fork deformity, produced by dorsal displacement of the distal fracture fragments.

    Palpation: Note any step-off, crepitus, and the point of maximal tenderness

    Test neurovascular status: Acute median nerve compression is common in these injuries, especially in severely displaced, high-energy fractures. Pay close attention to finger sensation.

    Evaluate for a distal radioulnar joint (DRUJ) dislocation: Caused by a disruption of the triangular fibrocartilage complex which stabilizes the joint. Orthopedic consultation is necessary for this injury.

       X-rays may be reported as normal; physical examination is the key to diagnosis

       Wrist has limited range of motion, with crepitus on supination and pronation

       Loss of the ulnar styloid contour with volar ulna dislocation and prominence of the ulnar styloid with dorsal dislocation

       More frequently with associated ulnar styloid fracture

    Evaluate for a Salter–Harris type I fracture in pediatric patients

       Tenderness over the distal radial physis

       Only radiologic finding may be displacement or absence of the pronator quadratus fat pad sign

       Low threshold to splint and arrange orthopedic follow-up

       Rarely results in a growth disturbance

       Consider child abuse in patients <1 year of age with this injury (FIGURE 50.1)

 Hematoma Block

    Prepare skin over fracture site with povidone–iodine or chlorhexidine solution

    Insert a 25-gauge needle dorsally into the hematoma at the fracture site approximately 30 degrees to the skin. Guide the needle tip into the fracture space by sliding along the fractured surface of the distal fragment. Placement is confirmed by the aspiration of blood.

    Slowly inject 5 to 10 mL of 1% lidocaine without epinephrine into the fracture cavity and another 5 mL into the surrounding periosteum

       Lidocaine will provide anesthesia for approximately 1 to 2 hours

       Bupivacaine 0.5% may also be used if available and has a significantly longer duration of action (4 to 6 hours)

    Allow 10 to 15 minutes for the anesthesia to become effective

 Reduction (Jones Method): Goal is to restore the normal anatomy (radial height, radial inclination, volar tilt, and intra-articular step-off) through traction and manipulation (FIGURE 50.2)

    Place patient’s fingers in a finger trap device with the elbow in 90 degrees of flexion

    Suspend 8 to 10 lb of weight from elbow (distal humerus specifically) for 5 to 10 minutes to disimpact fracture fragments

    While in traction, apply dorsal pressure over the distal fragment with your thumbs while simultaneously applying volar pressure over the proximal segment with your fingers to continue to disimpact the fragments

    Apply volar force to the distal fragments to realign them into anatomic position

    Remove the traction weight

 Splinting: A sugar-tong splint maintains the reduction and allows for swelling without compromising circulation

    Extends from the dorsal metacarpal–phalangeal joints around the elbow to the midpalmar crease

    The splint should be premeasured and created with six to eight layers of thickness

    The elbow is placed in 90 degrees of flexion, the forearm in pronation, and the wrist in slight flexion and slight ulnar deviation

       Extensive flexion, >20 degrees, can cause median nerve compression

       The position of the forearm can be controversial (neutral vs. slight supination). Leave the decision up to the orthopedist who will be following up with the patient.

       The metacarpal–phalangeal joints should not be immobilized to reduce the risk of potential stiffness

    A reverse sugar-tong splint provides an equally effective alternative to the traditional sugar-tong splint, while avoiding splint buckling at the elbow. In this case, the splint fold will be located distally at the first web space of the hand, instead of at the elbow as described above (Figure 50.2).

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